Bankruptcy Client Intake Form

Bankruptcy Client Intake Form — Form Fields

This legal template includes 13 fields. Gather financial and personal information from a client seeking bankruptcy relief under Chapter 7, 11, or 13. Free to customize and use on ZenBuild.

• Client Full Name (text, required)
• Client Email (email, required)
• Phone Number (text, required)
• Home Address (text, required)
• Bankruptcy Chapter Seeking (dropdown selection, required) — options: Chapter 7 (liquidation), Chapter 11 (reorganization – business), Chapter 13 (repayment plan), Not sure – need assessment
• Have you filed for bankruptcy before? (multiple choice, required) — options: Yes, No
• Prior Filing Date and District (if yes) (text, optional)
• Monthly Gross Household Income (USD) (number, required)
• Total Estimated Debt (USD) (number, required)
• Types of Debt (checkboxes, required) — options: Credit cards, Medical bills, Student loans, Tax debt, Mortgage arrears, Auto loans, Business debt, Other
• Summary of Major Assets (long text, optional)
• Are you currently facing wage garnishment, foreclosure, or repossession? (multiple choice, required) — options: Yes, No
• Additional Financial Context (long text, optional)